Provider Demographics
NPI:1770625527
Name:CHILDREN'S HOME OF JEFFERSON COUNTY
Entity type:Organization
Organization Name:CHILDREN'S HOME OF JEFFERSON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MONNAT
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:315-777-9747
Mailing Address - Street 1:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-777-9747
Mailing Address - Fax:315-785-5637
Practice Address - Street 1:211 JB WISE PL
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2507
Practice Address - Country:US
Practice Address - Phone:315-779-1507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02502243Medicaid